This year, the Agency for Health Care Administration begin inspecting Home and Community Based Services’ (HCBS) based on the requirement for Person Centered Planning. Based on Florida’s waiver, residents of assisted living facilities would need to be assessed by the facility to determine their needs. Keep in mind that this is not a nursing assessment, but rather an assessment of the persons’ total health and integration from a lay-persons' perspective. This means, you have to speak with the resident and determine what they believe they need in order to feel a sense of community integration and community involvement. We often use the catch phrase dignity and respect, but forget that seniors also want to continue leaving a life of "purpose." This plan provides an opportunity for the assisted living facility to help the seniors within their community with a new sense of purpose, or stated differently, the motivation that drives them towards a satisfying future. A future that they continue to own even in their latter years.

When drafting the plan, you should think about gathering information about the person’s current situation, previous situation, their goals, likes, and dislikes. For example, one goal of a resident that is transitioning to your assisted living from a hospital may be to regain more use of her right arm after a stroke. Keep in mind that this is a fluid conversation, and you can suggest goals with the resident and determine if they agree that it should be a realistic goals.
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The facility will need to get the entire care team involved to determine the types of services that will be offered by physical therapy, home health, the facility and the family. The plan is to make the resident a part of the health care decisions. It may not be a formal meeting with the resident and everyone all the time, but gather as much information from everyone that comes into the building that interacts with the resident. Remember, the Plan is fluid and changes. You should be updating them at least yearly.

I think back on my mom having early onset dementia, trying to articulate and find words to talk to everyone in the room about the decisions that were being made. Although her statement to the nurse, physician, and to all the family in the room was not a complete sentence, she yelled, “no one asked me what I wanted to do.” It made sense, because she had good days and bad days, but that was a great day. It really hit home for my family. We were expressing our wishes and failed to even consider her opinion because we believed she would like to see happen.

In short, think about the resident and be inclusive. You can find a sample of a person centered plan in the FALA member’s toolbox.